Follow-up 10 years later of 34 Klinefelter males with karyotype 47,XXY and 16 hypogonadal males with karyotype 46,XY

Social Management Training in Males With 47,XXY (Klinefelter Syndrome): A Pilot Study of a Neurocognitive-Behavioral Treatment Targeting Social, Emotional, and Behavioral Problems

Klinefelter syndrome (47,XXY) is associated with problems in social interaction and behavioral adaptation. Sixteen adolescents and adult men with 47,XXY enrolled in a pilot-study evaluating the effectiveness of Social Management Training (SMT), a novel neurocognitive-behavioral treatment program targeted at improving social, emotional, and behavioral functioning. Participants reported improved emotional stability from pre- to post-test (5 months). Informants reported reductions in internalizing and externalizing symptoms, including improvement in self-regulation. Although informants did not report changes in autism-like symptoms, increased awareness of social challenges was found. SMT may improve emotional stability, self-regulation, and self-reflection in people males with Klinefelter syndrome. This potentially efficacious treatment approach may prove to be a promising psychosocial therapeutic intervention for this population.

Transsexualism in a Klinefelter male: a case report

We report a Klinefelter male who presents requesting gender reassignment surgery. There may be a predisposition to gender dysphoria in Klinefelter's Syndrome, and in the case we describe, the perception of his symptoms as being of biological origin coupled with the unavailability of gender reassignment surgery in the Republic of Ireland has had a negative therapeutic effect.

The natural history of endocrine function and spermatogenesis in Klinefelter syndrome: what the data show

Once thought to be a chromosomal aberration associated with absolute sterility, Klinefelter syndrome may now be potentially treatable by testicular sperm retrieval coupled with intracytoplasmic sperm injection. With these therapeutic advances, azoospermic 47,XXY men now may have an opportunity for biological paternity. However, our knowledge of the basic mechanisms underlying germ cell loss and Leydig cell compromise is lagging, and is just now beginning to evolve and provide answers to some of the field's most vexing questions: how to maximize and preserve fertility in Klinefelter males many years or even decades before they wish to actively pursue fatherhood. This article reviews the development of the androgenic and spermatogenic compartments of the Klinefelter testis through puberty, and recommends that it is only with a clear understanding of the basic facts that a rational, considered approach to fertility optimization and preservation can be determined.

Klinefelter syndrome in clinical practice

Klinefelter syndrome is the most common sex-chromosome disorder; it affects approximately one in every 660 men. This syndrome is characterized by the presence of one or more extra X chromosomes, and the karyotype 47,XXY is the most prevalent type. The 'prototypic' man with Klinefelter syndrome has traditionally been described as tall, with narrow shoulders, broad hips, sparse body hair, gynecomastia, small testicles, androgen deficiency, azoospermia and decreased verbal intelligence. A less distinct phenotype has, however, been described. Klinefelter syndrome is an underdiagnosed condition; only 25% of the expected number of patients are diagnosed, and of these only a minority are diagnosed before puberty. Patients with Klinefelter syndrome should be treated with lifelong testosterone supplementation that begins at puberty, to secure proper masculine development of sexual characteristics, muscle bulk and bone structure, and to prevent the long-term deleterious consequences of hypogonadism; however, the optimal testosterone regimen for patients with Klinefelter syndrome remains to be established.

Klinefelter's syndrome (XXY) as a genetic model for psychotic disorders

Males with an extra-X chromosome (Klinefelter's syndrome) frequently, although not always, have an increased prevalence of psychiatric disturbances that range from attention deficit disorder in childhood to schizophrenia or severe affective disorders during adulthood. In addition, they frequently have characteristic verbal deficits. Thus, examining brain magnetic resonance imaging (MRI) scans of these individuals may yield clues to the influence of X chromosome genes on brain structural variation corresponding to psychiatric and cognitive disorders. Eleven adult XXY and 11 age matched XY male controls were examined with a structured psychiatric interview, battery of cognitive tests, and an MRI scan. Ten of eleven of the XXY men had some form of psychiatric disturbance, four of whom had auditory hallucinations compared with none of the XY controls. Significantly smaller frontal lobe, temporal lobe, and superior temporal gyrus (STG) cortical volumes were observed bilaterally in the XXY men. In addition, diffusion tensor imaging (DTI) of white matter integrity resulted in four regions of reduced fractional anisotropy (FA) in XXY men compared with controls, three in the left hemisphere, and one on the right. These correspond to the left posterior limb of the internal capsule, bilateral anterior cingulate, and left arcuate bundle. Specific cognitive deficits in executive functioning attributable to frontal lobe integrity and verbal comprehension were noted. Thus, excess expression of one or more X chromosome genes influences both gray and white matter development in frontal and temporal lobes, as well as white matter tracts leading to them, and may in this way contribute to the executive and language deficits observed in these adults. Future prospective studies are needed to determine which gene or genes are involved and whether their expression could be modified with appropriate treatments early in life. Brain expressed genes that are known to escape inactivation on extra-X chromosomes would be prime candidates.

Androgen insensitivity syndrome and Klinefelter's syndrome: sex and gender considerations

Two of the most common intersex conditions, androgen insensitivity and Klinefelter's syndrome, are described with an emphasis on aspects that are of relevance to psychiatrists. Attention is focused on commonalities and differences between these syndromes and particular attention is given to how persons who have these conditions manifest sexual and gender adjustments to their situations. Tips on counseling and medical management are offered.

An XXYY male with schizophrenia

OBJECTIVE

A case of XXYY associated with schizophrenia is presented.

CLINICAL PICTURE

A European male with tall stature, hypogonadism, and mild grade intellectual handicap with significantly lower verbal than performance Intelligence Quotient (IQ) exhibited features of chronic paranoid schizophrenia, along with impulsive aggression.

TREATMENT AND OUTCOME

A trial of testosterone replacement exacerbated aggression. Psychotic symptoms persisted despite antipsychotic therapy.

CONCLUSIONS

This is perhaps the first report of the XXYY syndrome associated with schizophrenia. The psychosis occurs more often in XXY and XXX than normal subjects, providing a clue to locating a gene predisposing to schizophrenia.

Testosterone treatment of an XXYY male presenting with aggression: a case report

A hypogonadal male with 48 XXYY Karyotype--a rare Klinefelter's syndrome variant--is presented with review of the literature. Cautious initiation of testosterone replacement therapy to our patient was associated with sexual maturation and, interestingly enough, disappearance of his longstanding aggressive fantasies and behaviors towards females. An explanatory hypothesis is proposed and clues for early detection of the syndrome are suggested.

Verbal deficits in Klinefelter (XXY) adults living in the community

Forty-two adult males--10 with Klinefelter's syndrome (karyotype XXY), 17 with normal sex chromosome karyotype (XY) but with physical signs of hypogonadism, and 15 presumed to be normal both chromosomally and hormonally--completed tests of Verbal and Nonverbal ability. It was predicted: a) that the XXY group would perform more poorly than the other two groups on tests of Verbal ability, and b) that the XY, hypogonadal group would perform more poorly than the others on tests of Non-verbal ability. The first hypothesis was supported. However, in spite of measurable verbal deficits, the XXY men (whose parents were more highly educated than those of the other two groups) did not appear to be underachievers. Rather, they were, in general, as well educated, as likely to be employed, and of socioeconomic status equivalent to that of the other men in the study. These findings are discussed briefly in terms of implications for early childhood education and genetic counselling. The second hypothesis was not supported: this is attributed to presumed heterogeneity of etiology of hypogonadism in the XY, hypogonadal group.

Follow-up 20 years later of 34 Klinefelter males with karyotype 47,XXY and 16 hypogonadal males with karyotype 46,XY

A 20-year follow-up study of 50 hypogonadal males has been made. Of these 34 had Klinefelter's syndrome with the karyotype 47,XXY and 16 had the karyotype 46,XY. These males have been examined at mean ages of 27 and 37 and in the present study at a mean age of 47. At the first examination the following conditions were found in the Klinefelter males to a significantly higher degree than in the hypogonadal males with 46,XY: immaturity, below average school performance, few or no friends, previous mental illness, little energy and initiative, few or no spare time interests, occupation as an unskilled labourer. Psychological testing showed a full scale IQ of 103 in the Klinefelter males and 115 in the hypogonadal males. The follow-up studies have shown that in spite of these findings the Klinefelter males have managed far better than could have been expected at the time of the first investigation. The improvement in a number of conditions such as mental health, working capacity, social adjustment, relations with other people, and activity level was considerable between the ages of 27 and 37. The present examination shows a further improvement at the age of 47 with the only significant difference between the Klinefelter males and the hypogonadal males with 46,XY being a higher frequency of single Klinefelter males. The present examination also showed that there was no significant difference between the two groups in occupation, working capacity, social adjustment, mental and physical disorders or criminality. The results of the examination at the mean age of 27 would probably have been considerably more favourable for the Klinefelter males if diagnosis had been made in childhood, and information, counselling, support and hormone treatment had been given from an early age. The fact that the great majority of the Klinefelter males have managed quite well in spite of this and that no remarkable differences were found between them and a control group is of great importance for genetic counsellers, especially for prenatal counsellers. Up until now, in 75% of cases in which sex chromosome abnormalities, including Klinefelter's syndrome, have been diagnosed prenatally in Denmark abortion has been induced. We believe this is mainly due to insufficient information about the many positive aspects of the development of individuals with sex chromosome abnormalities.

Klinefelter's syndrome and psychopathology: a case study of the combined effects of nature and nurture

A patient with Klinefelter's syndrome and genotype 47 XXY was abused and ostracized by his family during childhood. Later, this pattern was repeated by a series of homosexual lovers. The separate and interactive effects between genetic and psychosocial risk factors may account for this patient's subsequent psychosexual and personality disorders and reminds scholars of psychopathology of the importance of early detection and intervention. This single case study is presented for heuristic value, illustrative purposes, and serves as a link between mental health clinicians and sexologists.

Schizophrenia and Klinefelter's syndrome

Psychiatric disorder in relation to Klinefelter's syndrome is reviewed. A well documented case report is presented of a schizophreniform illness in a patient with Klinefelter's.